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Homeowners Insurance Proposal Request

Please complete the following information if you would like to obtain a proposal on Homeowners Insurance. Once received we will contact you by phone. Please understand this is not an application for insurance nor does it bind any coverage. An application will be sent to you if coverage is desired.

All of the information provided is confidential and will be used solely for the purpose of developing a proposal for you.

The home may be a single family owner occupied dwelling (home), condo or town home. This program may provide (A) dwelling fire coverage, (C) contents (personal property), (D) loss of use, (B) separate structures such as a detached garage or shed, (E) premise medical and premise liability insurance.

Complete this form to get a proposal on a single family owner occupied home, condo or townhouse.

Fields marked * are required

Personal Information

Name *
Address *
City *
State *
Zip Code *
Phone Number *
Fax Number
Email Address *

Property Information

Property Address
City
State
Zip Code
Dwelling Type
Number of Bedrooms
Number of Bathrooms
Number of Fireplaces
Number of Porches or Decks
Year Built
Purchase Date
Construction Type
Stories
Ground Floor Square Footage
Total Square Footage
What foundation type?
If structure is located in a flood zone, what is the distance to body of water?
What type of garage?
What type roof covering?
Was the roof updated?	Yes No
If yes, what year was it updated?
Pool	Yes No
Pool Fence	Yes No
Pool Diving Board	Yes No
Pool Slide	Yes No
What is the distance of fire protection?
Smoke Alarm	Yes No
Fire Extinguisher	Yes No
Deadbolts	Yes No
Electrical Update
Circuit Breakers	Yes No
Copper Wiring	Yes No
Age Heating/ Air Conditioning
Thermostatically Controlled	Yes No
Energy Source
Heating System
Cooling System
Plumbing Updated	Yes No
Copper Plumbing	Yes No
Automatic Fire Sprinklers	Yes No
Theft Alarm	Yes No
Fire Alarm	Yes No
What is the fire district?
Dogs on Property	Yes No
If yes, how many and what is the breed of each dog?
Pets or Animals	Yes No
If yes, how many and what is the description of each?

Current Coverage Information

What is the current insurance company?
What is the expiration date of current policy?
Were there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of each loss or claim?

Desired Coverage Information

Dwelling Amount
Other Structures
Business Property
Loss of Use
Premise Liability
Policy Deductible Amount
Do you want building replacement cost coverage?	Yes No
Do you want contents replacement cost coverage?	Yes No
Questions or Comments

Best Time to Contact You

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